Learning to breathe again

By: Jessica Garabon

Every so often I have to learn to breathe again…

It sounds like such a silly statement.  Breathing is something that we are innately programmed to do. But when I was asked to describe my experience with depression and generalized anxiety disorder, this was the only phrase that began to describe it. It is like learning to breathe over and over again.

My struggles with mental health have been present for most of my life. However, it wasn’t until three years ago that I could put a name to what I was experiencing – when I was diagnosed with both generalized anxiety and major depressive disorders. I had experienced many of the symptoms encompassed in these two conditions since I was a child. But because there was nothing medically “wrong” with me, I was labelled as moody, overly emotional, or disruptive. For the next several years of my life, I internalized the thoughts and feelings that I was experiencing as myself just overreacting or getting worked up over nothing. I placed an inordinate amount of blame on myself and resolved to move past these scenarios and just “be better”.

Throughout high school and university, the anxiety and emptiness that I experienced were magnified. The funny thing was, if you asked anyone in my life from my close friends to casual acquaintances, they would describe me as being incredibly happy all of the time. Sure, I knew that away from the gaze of others I would have bad days or weeks, but I would also have periods of unequivocal happiness where I couldn’t wait to see what the future would hold for me, so how could I possibly be depressed? Over time, the periods of depression and crushing anxiety began to grow longer and the moments of happiness became increasingly less frequent. Even when you need it the most, reaching out for help is an incredibly difficult feat. I found this to be especially true because I didn’t know how to define what I was experiencing yet. Was I over-reacting? Was this something that everyone goes through in university? How could I ask for help when I didn’t even know what I needed help with? With time, I finally made the decision to reach out to my doctor. Being formally diagnosed gave me a strange sense of closure. I could finally put a name to my illness. A name that made me feel even the slightest bit that my struggles were validated. I felt excited and hopeful about my future. I knew what was wrong with me and now I could go out and fix it. Like I have found time and time again, life just isn’t that simple.

When I started medical school, it was meant to be the happiest time in my life. I had worked for it for years and dreamed of it for even longer. I had always believed that my depression and anxiety were centered around my unhappiness with where I was at in life. If I could accomplish more, do better, be better then I wouldn’t have this weight hanging over me. In a one-year period I married my high school boyfriend, completed my master’s degree, and was accepted into medical school- everything I had dreamed of was finally at my fingertips. At this time, I thought that I would finally be free of the depression and anxiety that had haunted me since I was a child. I was exactly where I wanted to be in life. But as I sat there during my medical school orientation, I felt the familiar pain of not being able to breathe.

From that moment on, I fell into a depression deeper than I had ever experienced. Depression and anxiety have become colloquial terms that are thrown around to superficially talk about mental health but being suicidal isn’t something that is often spoken of. Suicide is an uncomfortable topic that is often shied away from in conversations about mental illness, but it is a very real and prevalent issue, especially within the medical community. Because of the prevalent stigma that comes along with speaking of being suicidal, I was afraid to reach out and ask for the supports that I needed. How could the girl who was always smiling and supportive, the person that classmates would go to for advice, the student body president be suicidal or suffering from depression? How could I ever be the doctor when I was also the patient?

In starting medical school, I had endeavored to keep my illness a secret. I believed that if my new peers discovered what I was hiding, the imposter syndrome that I so often experienced would be validated by all of those around me. I began to worry about how dealing with mental illness would affect my future career as a physician. But I have decided that I refuse to be part of a healthcare system where I will be stigmatized for being both a physician and patient.

My story is not special, and it is not unique. There are an endless number of people like me, who have experienced this kind of hardship and still persevere every single day. I’m still sick, and I believe that these are issues that I will continue to manage for the rest of my life. But my perspective on my illness has changed. I’ve started talking more openly about my mental health with those in my life. Normalizing my illness has given me the strength that I need to learn how to breathe again one day at a time. I’m slowly learning to trust others and that I don’t need to carry the weight of my illness all on my own. I have built the most incredible support system, and I could not be more thankful for the endless number of people that have demonstrated kindness and compassion and friendship throughout my journey. I take the medications that I need to allow my brain to function normally, and I continue to work on myself every day with the help of an incredible psychiatrist who is well-versed in physician and trainee mental health. I’m not okay today, but I know that I will be one day. I know that I have a future with love and hope and happiness. I know that my experiences with depression and anxiety will help me to be a more compassionate and empathetic doctor. I know that one day I will breathe freely again.

As I continue to move forward in my journey, there are a number of realizations that I’ve made that have contributed to my recovery. First, I have spent most of my life searching for my purpose; seeking out greater meaning in the world and the one ultimate source of happiness to light a spark inside me and show me why I’m here. This is something that I have spent years searching for but have never found because life is just not that simple. One of my closest friends has helped me to realize that life is not black or white. Good or bad. Pure or evil. Just as happiness isn’t one grand event or nothing at all. She has shown me that happiness isn’t a destination or one occurrence in life that we get to experience. Happiness, as cliché as it may sound, is a collection of tiny moments in everyday life than can bring joy and appreciation and love. These moments can be as simple as having coffee with a friend in the middle of a hectic day, spending an hour at the park with my dog, sleeping in without an alarm, or hearing the purest and most magnificent belly-laugh of my husband. Any of these moments alone are not momentous or overly significant, but together they form a life filled with purpose and meaning and value and hope.

Now, during difficult days, there is a quote that I like to remind myself of by one of my favourite authors Jamie Tworkowski:

“Your questions deserve answers, but just as much, you deserve people who will meet you in your questions. Some answers will take years. Some answers will take a lifetime. The questions often weigh so much. The good news is you don’t have to carry them on your own. This life, our healing, our recovery, it is certainly a journey. What a miracle that we don’t have to do it alone.”

Despite the difficulties and uphill battles that I still continue to face. Despite the struggle of facing a world that continues to stigmatize and cower away from my illness. Despite the beautiful and wonderful days that can be interrupted unexpectedly by a familiar sense of being unable to breathe, I am not alone. What a miracle that I don’t have to do this alone.

Author: Jessica Garabon

Jessica completed her B.Sc. in Behaviour, Cognition, and Neuroscience at the University of Windsor and her M.Sc. in Neuroscience at Western University. She is the incoming Hippocratic Council President and a proud co-founder of Proaction on Mental Health (PRO-MH). Jessica is passionate about narrative medicine and being an advocate for physician and trainee mental health. She loves travelling and coffee and is a fierce supporter of the Oxford comma.
This post was inspired by Proaction Mental Health, a new social 
movement created by Schulich medical students to tackle the stigma
of mental health, and to provide a strong supportive community among
future healthcare professionals. Follow them at @proactiononmh on
Instagram and Twitter!
Photo Credits: Breathe, Creative Commons 

Part 2: The Philosopher Emperor

By: Eric Di Gravio

Marcus Aurelius: In the Capitoline Museum

In my previous blog post, I started to describe how Marcus Aurelius thought that we should face all our struggles without complaint. But where does the strength to do this come from? Let’s continue with what Marcus thought the answer to that question was:

You have power over your mind-not outside events. Realize this, and you will find strength.

A strong person, according to Marcus, recognizes that strength comes from within. It’s in our thoughts and in how we choose to perceive the world around us. The Stoic philosophy that Marcus learned as a young adult taught him that no events which happen are in themselves evil, it’s only our perception of them that is evil. If we have the inner fortitude and belief that we will overcome whatever hardship we are facing, then that is the source of true strength. Marcus explains this well and takes it a step further when he says:

Apply this principle: not that this is a misfortune, but that to bear it nobly is good fortune.

Again, it all comes down to perception. Question yourself: Is this difficult task or unfortunate event really a bad thing, or is it simply an opportunity to make myself better? If we begin to face our problems with this in mind (which I understand is no easy feat), then we will be facing it with all the strength we can muster, and we can’t ask for much more than that.

One last passage on this topic that I found particularly powerful is the following:    

Thou sufferest this justly: for thou choosest rather to become good tomorrow than to be good today.

Medical school and being a doctor isn’t going to be easy, it was never going to be. But all the exams we write, the facts we memorize, the patients we will see and inevitably, the mistakes we will make along the way, are simply necessary steps to make us better people, and doctors of tomorrow. 

What Motivates Us

In his Meditations, Marcus spends much time discussing the purpose of his life. As he mentions over and over again, he finds the praise of others (remember that he was considered a god), the pursuit of fame, glory and wealth all as hollow things. His line of thinking is, if everything including yourself is transient, then what is the point of achieving fame and glory when people are bound to forget you eventually? As Marcus says:

What is even an eternal remembrance? A mere nothing.  What then is that about which we ought to employ our serious pains? This one thing, thoughts just, and acts social, and words which never lie, and a disposition which gladly accepts all that happens

This was not meant to be some doom and gloom statement about how we are all going to die and nothing matters. Instead, by constantly repeating statements like the ones above, Marcus was attempting to keep himself well-grounded and not to get caught up in all the extravagances that many prior, and certainly many later emperors did. He was reminding himself then, and us now, what the truly important things in life are: acting justly and for the common good, and being thankful for what life has given you. Marcus then goes a step further and says:

Have I done something for the general interest? Well then I have had my reward. Let this always be present to thy mind, and never stop doing such good.

Here again, Marcus is reiterating the fact that acting for the common good is the highest reward one can receive, even if its not appreciated at the time. Indeed, it is the very act of working for the common good that should serve as our motivation for everything we do. In other words, the most important thing is being able to go to bed each night with the satisfaction of knowing that we helped someone that day, and that that act in and of itself should be all we need to keep us satisfied and motivated.

Final Thoughts

I couldn’t help but wonder what Marcus would say if now, almost 2000 years later, I were to ask him for one piece of advice about how to be a good person and leader. But then I came across this passage in Meditations that I think answers that question pretty clearly.

Waste no more time arguing what a good man should be. Be one.

Alright then Marcus, point taken. I guess he would say that we all already have it in our hearts what it takes to be a good person and doctor, we just have to have the strength and dedication to do it.

A note on translations:

Since the Meditations are essentially Marcus’s reflections on the philosophical school of thought called Stoicism, and the vast majority of philosophical teachings at the time were written in Greek, Meditations too was written in Greek (even though Latin is the language most commonly associated with Ancient Rome). As in any work of literature originally written in ancient Greek, there are various different translations which all have the same essence, but with slightly different wording. Therefore, if you look up these quotes online or have heard/read a slightly different quote than one I have used here, note that it is simply a different translation of the same piece of work, and hopefully you can see that it captures the same meaning.

Select Quotes from Meditations:

  • “And though wilt give thyself relief, if thou doest every act of thy life as if it were the last, laying aside…discontent with the portion which has been given to thee.”
  • “Short then is the time which every man lives, and small the nook of earth where he lives; and short too the longest posthumous fame”.
  • “Which of these things is beautiful because it is praised, or spoiled because it is blamed? Is such a thing as an emerald made worse than it was, if it is not praised?”
  • “The best way of avenging thyself is not to become like the wrongdoer.”
  • “Let not future things disturb thee, for thou wilt come to them, if it shall be necessary, having with thee the same reason which now thou usest for present things.”
  • “No man can escape his destiny, the next inquiry being how he may best live the time that he has to live.”
  • “Look within. Within is the fountain of good, and it will ever bubble up, if thou wilt ever dig.”
  • “Neither in thy actions be sluggish nor in thy conversation without method, nor wandering in thy thoughts…nor in life be so busy as to have no leisure.”
  •  “This too is a property of the rational soul, love of one’s neighbour, and truth and modesty.”
  • “If it is not right, do not do it: if it is not true, do not say it.”

Author: Eric  Di Gravio

Eric is a second year medical student at Western University. He also completed his BMSc in Biochemistry of Infection and Immunity here at Western. Eric is a self-proclaimed history buff but also enjoys basketball and attempting (and failing) to match his grandmother’s cooking skills.
Sources: 
Photo Credit: Marcus Aurelius, Creative Commons

The Philosopher Emperor

By: Eric Di Gravio

Equestrian Statue of Marcus Aurelius, Rome

Part 1

I have always considered myself a history buff. I will admit, I still pride myself on my collection of books accumulated from childhood that fill my room. While history has always been a hobby of mine, as I got older, I found myself finding inspiration in the lives and exploits of men and women throughout history; from ancient Mesopotamia to the global conflicts that shook our world in the 20th century. Since starting medical school, I now find myself reflecting on what it means to be a ‘good doctor’ and have begun to see the stories of these same men and women in that new light. Recently, I have been on a bit of an ancient Rome/Greece binge and in doing so have come across (again) the writings of the Roman Emperor Marcus Aurelius (yes, the old emperor in Gladiator). For reasons I will endeavour to share with you, I think that we have much to learn from this once beloved emperor about how to be a good person and by extension, good doctors. But first, let us start with some background.

Importance of the Roman Empire

Ask someone to blurt out the first thing that they think of when you say “Roman Empire” and chances are it will be the Coliseum, gladiators, togas or Julius Caesar. But the Roman Empire has given us so much more than a trendy tourist hotspot, movies with Russel Crowe fighting sadistic emperors, toga parties or Caesar salad (spoiler alert, Caesar salad has nothing to do with Julius Caesar). Rome is everywhere, from the ruins left behind to the borders of our modern-day countries, even to the organization of our governments. But what can we learn from the people, places and history of 2000 years ago? While that is a question that countless classical historians have spent their lives trying to answer, what I add is this: the world of the ancient Romans that Marcus Aurelius knew was not so different from ours. Just like us today, the ancients worried about the economy, national security, religion, politics, healthcare and countless other existential crises.

Who was Marcus Aurelius?

Born in 121 AD in Spain, Marcus Aurelius was adopted by his uncle and future Roman Emperor Antoninus Pius as his son and heir to the throne. Upon becoming emperor after the death of Antoninus, Marcus devoted much time to reforming the law to be fairer for the poor and powerless, promoting free speech, stabilizing the armies and boosting the economy. For this and for his famously humble and simple personal life, Marcus is known as the last of the five “Good Emperors” and the last emperor of the “Pax Romana (Roman Peace),” stretching from the first emperor Augustus all the way to Marcus, a period of about 207 years. While there has certainly been some romanticising of this era in Roman history, there is no doubt that these years saw Rome at the height of its power in terms of economic wealth, territorial extent, military success and relative peace within its borders. After the death of Marcus, the Roman empire fell under increasingly more despotic emperors, witnessed decades of civil war and economic recession, and never truly regained the same power, influence and wealth that it had enjoyed previously. 

Marcus’ biggest claim to fame however remains his Meditations. While by day Marcus was fending off the invasion of the Germanic “barbarians” into the Roman empire, by night he was writing in a personal diary his daily thoughts and feelings. Never intended for the public eye, Meditations reflect the inner thoughts of Marcus at his most vulnerable and dark times while he reflects back on the teachings of the Stoic school of philosophy that he had learned as a young man. Preserved after the death of Marcus, this diary allows us a glimpse into the thoughts of one of the most humble and down-to-earth people to ever live, let alone be an emperor. Reading his work, you get no hint that this was written by one of the most powerful men, in one of the most powerful empires ever to set foot on the world (considering that Roman emperors were basically treated as gods on Earth). Just like many people before me, I too have found inspiration in the words of Marcus and think that there is something in them that can give us some insight into how to be good people, and by extension, good doctors.

Following then, is a collection of some of the lessons I believe we all can learn from Marcus.

On Handling the Tough Times

Even though he was an emperor, Marcus was no stranger to struggle. Death loomed heavy over his head as he witnessed both the death of many of his children, and also the eventual death of his wife. Even Marcus himself was a sickly man, (although we don’t know his exact ailment today) his seemingly impending death seemed often to be on his mind throughout Meditations. Apart from personal struggles, Marcus also had an entire empire to worry about. Early in his reign, he was fending off invasions from the Parthian Empire in his Eastern provinces. Even after a Roman victory, there was no time for rest, as very soon after there was a plague (likely smallpox) that ravaged the empire, closely followed by an invasion of Germanic “barbarians” along the northern border… and it keeps going. 

The biggest lesson I think we can learn from Marcus in this regard is best summarized by this passage in Meditations:

‘A cucumber is bitter.’ Throw it away. ‘There are briars in the road.’ Turn aside from them. This is enough. Do not add, ‘And why were such things made in the world?’

            The lesson that Marcus has captured in this passage is the fact that hardships will happen to everyone and there is no use thinking “why me?”. Marcus would say that instead of becoming upset that such things have happened, we should focus our energies on solving them and moving forward. Thoughts of “why me” or “this is such a waste of time, why do I have to do this” are in themselves “wastes of time” and don’t help solve the problem or complete the task at hand. 

But where does the strength to do this come from? Check out my next blog post to learn where Marcus thought the answer to this question laid. 

Author: Eric Di Gravio

Eric is a second year medical student at Western University. He also completed his BMSc in Biochemistry of Infection and Immunity here at Western. Eric is a self-proclaimed history buff but also enjoys basketball and attempting (and failing) to match his grandmother’s cooking skills.
Sources: 

Let’s open up the conversation about death

By: Christopher Creene

I’ve been thinking about my Dad a lot recently. Another February 4th has come and gone, and this year it marked 8 years without my Dad. When asked about my parents, I find myself speaking about my Dad in present tense as if he is still with us, failing to mention that he passed away from a heart attack soon after we moved to Canada.

Why?

Don’t get me wrong – I want to talk about him. I want to share fond memories of him, and laugh about the antics he used to get up to. But over the past few years I’ve become increasingly aware of the ‘social taboo’ that exists around death. People get awkward and don’t know where to look when you talk about someone close to you dying. It makes people feel uncomfortable. So I’ve learned not to bring it up, to pretend it didn’t happen. I’ve met all kinds of wonderful people since moving to Ontario last year, but in that time I have only told one person about the death of my father. It’s with such regret that I feel I need to hold back on talking about the man who made me who I am today. He was a wonderful role model to my siblings and I, and a dearly loving husband to my mother. I have such pride in saying that he is my father.

Whilst writing this blog entry, I started to wonder how other people felt about this topic after losing someone they love. I reached out to one of my best friends, an incredible guy who I’ve known for many years now. His younger brother was tragically killed by a drunk driver 3 years ago. This is what he had to say:

“In my experience, I feel that those who aren’t your family don’t want to hear about your hardships. I think that’s mainly because it makes them feel sad, and it makes them worry that YOU could become upset, at which point they’d have to console you. Also, in general I don’t want people to pity me. I want people to do/say nice things for/about me not because they pity me, but because they respect me.”

His words perfectly describe what I’m trying to get across, and it was interesting to hear that I am not the only person who feels this way.

I’ll admit that prior to experiencing loss myself, I responded to death in a similar way. It made me uncomfortable, and I would avoid talking about it to prevent others from becoming upset. I felt that because I couldn’t relate, any words of comfort that I provided would lack authenticity. This is one of the main reasons why I felt that it was important to write this blog entry, as a way to share my personal experiences as someone who now understands, and to give advice on how I think we should be addressing the subject.

So how do you respond to someone sharing their grief with you?  How can we normalize death and open up the conversation?

The major misconception that I think needs to be cleared up is that you should avoid talking about someone’s loss because it will make them upset. Although different people grieve in different ways, my general experience has been that people want to talk about a lost loved one. By talking about that person, you keep their memory alive. The next time someone shares this personal part of their life with you, don’t shy away from the topic. Ask them ‘What was she/he like? What’s your favourite memory with them? What were his/her hobbies?’. Personally, I love talking about my Dad – it helps me keep him close.

Of course, sometimes I do get upset when talking about him. But that doesn’t mean that you should avoid bringing it up! In writing about the death of a close friend, Alfred Lord Tennyson wrote “’tis better to have loved and lost than never to have loved at all”. When someone dies, the family and friends left behind don’t want to just pretend that person never existed. We want to talk about the music they liked and the jokes they used to make. We want to talk about precious memories and laughs we shared. But I’ve found it difficult to do so because over the years I’ve been met with discomfort and avoidance when I bring it up. I’m asking you, the reader, to help open up the conversation. By talking about them we can keep them as a part of our daily lives, even if they’re not physically with us anymore.

I’ll finish with a quote that someone shared with me when my Dad died. It means a great deal to me and it sums up my message wonderfully:

They say a man dies twice. Once when he stops breathing and the second, a bit later on, when somebody mentions his name for the last time.”

Author: Christopher Creene


Christopher grew up in Bristol, England, and moved to Canada when he was 15. He completed a BSc. in Microbiology & Immunology at Dalhousie University, and subsequently spent a year working at the QEII Health Sciences Centre as a phlebotomist. He is now on his way to completing his first year of medical school at Schulich. He is passionate about running, music, and the environment.

Photo Credits: Flikr, Creative Commons

Views from Across the Rubicon: The Rejected Physician Services Agreement

crossing-rubicon

August 14, 2016 marks a turning point for the history of health care in the province of Ontario. 63.1% of Ontario Medical Association (OMA) members rejected the Liberal government’s proposed Physician Services Agreement (PSA) and in so doing voiced their vehement disagreement with the trajectory of health care in Ontario.

This is not meant as a criticism of the PSA even though it is an agreement that is certainly worthy of our criticism. It is worth recognizing the many rational reasons physicians had for voting for the proposed agreement. The Liberal Government of Ontario’s rejected PSA was beyond disastrous. It was bad for the health care system and economically untenable. It intentionally underfunded health care at a rate lower than health care growth and would have necessitated longer wait lists, clinic closures, doctor relocations to other provinces and countries, and the delisting of medically necessary services. It also would have significantly cut individual physician salaries on a progressive basis over four years after accounting for inflation. With all that said, I’m still surprised that the PSA failed to pass. The agreement was despicable in objective terms, but still managed to provide stability and predictability in its sadism. Rejecting the agreement once again puts Ontario’s doctors at the mercy of the Liberal Government, a government that has shown its willingness to engage in unilateral action, even at the expense of Ontario’s doctors, tax payers and patients. The Liberal Government will likely impose an even harsher version of the rejected PSA and pass bill 210 (the ironically named “Patients First Act”) unamended. Bill 210 is punitive in nature and cripples the ability of health practitioners to manage their own practice while grossly expanding the scope of powers of the Minister of Health.

After comparing these two options, voting “for” this agreement seems maddeningly reasonable. The Ontario Government assumed that physicians would vote in alignment with their self interests and begrudgingly vote in favor of the devil they knew. What Ontario’s doctors gained by voting against the PSA is not something that is tangible. Rejecting the PSA was our profession’s confessional – it was our moral absolution. We will not be complicit in the erosion of our health care system. We are its champions and we will stand and defend it.

The word “advocacy” gets thrown around a lot in medicine and is a concept that those within the profession are perhaps overly familiar with. “Advocate” is one of the six cardinal roles that the Canadian Medical Association (CMA) identifies for physicians and “advocacy” is a deeply ingrained tradition of medicine. Physicians strive to advocate for their patients whether it’s by raising awareness for mental health, providing refugees with medical care, helping patients get access to the medications they need or just providing Ontarians with humanity and excellence in medical care. Rejecting the PSA is advocacy on a system level.

The rejection of the PSA marks a philosophical stand against the dismantling of health care that comes at great personal and professional cost. The Ontario Government likely crafted this agreement so that they could obtain the coerced consent of the medical profession and use it to legitimize further and continued cuts to health care. The language of the agreement would have made physicians responsible for increases in health care utilization, which some have compared to making firefighters financially liable for the number of fires they have to put out. This would have given the government political ammunition to blame inevitable future increases in health care expenditure on physicians. Signing the PSA would have made further advocacy considerably more difficult. It would have transformed would be advocates into hypocrites. This was an agreement that in its essence demanded silence in exchange for a slight reduction in the immediate rate of health care cuts. The Liberal Government tried to manufacture consent and it failed.

I hope that the freedom to continue to meaningfully advocate against harmful pieces of legislation is worth the heavy price that was paid. The medical profession is in an extremely precarious position and will no doubt face some trying times ahead. I hope that our rejection of the PSA is proof that we cannot be broken and that we will continue to advocate even in the face of continued propaganda and retaliatory measures.  Ontario’s doctors must serve as a check against the Ontario Liberal Government and their apparently willful destruction of our health care system.

There will come a time when we look back and reflect on the events that led to the creation of our modern health care system. In 1946, Tommy Douglas introduced the Saskatchewan Hospitalization Act, which became the model for health care across Canada. In 1984, the Canada Health Act introduced universal health care across the nation. In 1991, the OMA agreed to become a closed shop organization with mandatory membership. In 2016, the OMA rejected the Province’s Physician Services Agreement. August 14, 2016 was a day of significance.

Ontario’s doctors have crossed the Rubicon.

Physician Burnout and the Cult of Medicine

I want there to be no mistake. Medicine is the most incredible profession. It intertwines a divine understanding of scientific principles with their very human application. It is one of the few professions that starts with atoms or cells and ends with people and emotions. It begins with universal laws and ends with subjective truths. Medicine is science, but it’s also poetry. Medicine exists in cosmic balance, but that balance is temperamental.

Those working within the health care profession are well aware of a phenomenon known as “physician burnout”. It is characterized by emotional exhaustion, depersonalization, cynicism and a lack of fulfillment. Studies estimate that physician burnout can affect as many as 65% of physicians. Many are surprised that such an intellectually and emotionally rich vocation can leave one drained and unfulfilled. Dr. Christina Maslach, an American psychologist and creator of the Maslach Burnout Inventory (MBI) perfectly described burnout as “an erosion of the soul”.

Maslach’s description makes a lot of sense to me because medicine is not a profession in the traditional sense. Medicine is a religion. It demands long hours and years of study – it demands sleepless nights and tireless days – in some aspects, it demands indoctrination.

We do not wear religious shawls, but we do wear white coats. We do not worship stars, crosses or crescent moons, but openly revere snakes coiled around a winged staff. Our holy text is the Hippocratic Oath and our prophets are many: Hippocrates of Kos, Galen of Pergamon, Lister of West Ham, and Koch of Clausthal are but a few. We even have modern day prophets like William Osler and Atul Gawande and false prophets like Ben Carson or Eric Hoskins.

Viewing medicine as a religion makes physician burnout easier to understand because a religion demands that life be made secondary to the divine. Medicine demands that patients always be put first and it demands that you live your life in the shadow you cast. Some have called medicine a Black Art and in some ways it is. It is perhaps the only profession that consumes the soul of the practitioner. The quest of medicine is Faustian. Many medical practitioners will pay a heavy price for the miracles they work.

I’ve read much of the literature on physician burnout and while the conclusions are accurate, they are often uninsightful. Deckard et al. (1994) correctly identify emotional exhaustion as the leading cause of burnout. Gundersen (2001) correctly concludes that certain personality profiles are more at risk of burnout. Shanafelt (2009) even claims that we can combat burnout by realigning organizational values such that patient care be given equal importance to physician well-being.

Shanafelt’s study best addresses the crux of the issue. Nothing will change unless we reorganize the value structure of medicine. Doctors burn out because they practice a toxic ideology. A man may subsist, but they cannot survive without a soul.

I believe that people really do go into medicine for noble reasons. They want to make a difference, help people… change the world, and are often willing to sacrifice themselves in the process. Unfortunately sacrificial offerings will not make the elusive “work-life balance” any easier to attain.

This is not a critique of medicine. I repeat that medicine is an incredible profession and one that I am grateful to be a part of. This is instead an invitation to examine one’s values and the values that are thrust upon us.

A man cannot sustain himself on ideology. Anyone who eats the body of Christ and nothing else will receive poor nutritional value. Surprisingly, the blood of the Lord is not rich in iron.

References

Deckard, G., Meterko, M., & Field, D. (1994). Physician burnout: an examination of personal, professional, and organizational relationships.Medical care, 745-754.

Gundersen, L. (2001). Physician burnout. Annals of Internal Medicine,135(2), 145-148.

Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach burnout inventory manual. Consulting Psychologists Press.

Shanafelt, T. D. (2009). Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA,302(12), 1338-1340.

Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., … & Oreskovich, M. R. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of internal medicine, 172(18), 1377-1385.

The Fiddler and the Fire: The Decline and Fall of The Health Care System

The Ancient Roman Empire did not fall in a day. And it certainly didn’t fall because barbarians were knocking at the gate. The decline and fall took hundreds of years while ignorance, apathy and conceit ate away at the soul of empire. Rome rotted from within.

The Canadian health care system is critically ill. We are faced with a rapidly aging population and health care expenditures that consistently rise faster than both the rate of inflation adjusted for population and provincial government revenues. The writing is on our crumbling walls. The signs are all around us. The Canadian health care system is fundamentally unsustainable, yet we shrug our shoulders and trudge on with the confident irreverence of Ancient Rome.

The Liberal Government of Ontario addressed this problem of unsustainability by conjuring the wisdom of charlatan economists. As health care expenditures continue to grow, the government will cut $580 million over two years while demanding that physicians shoulder the burden of increased health care costs through claw backs and reconciliation. An additional 1.3% cut was just announced September 2015, raising total cuts to 6.9% plus reconciliation and inflation. The situation is even worse for family practitioners, particularly new graduates who will be barred from joining Family Health Organizations. Year after year, health care costs will continue to rise. A policy of reconciliation cannot by definition provide a meaningful long-term solution. The government’s unilateral action demonstrates an unwillingness to engage with the Ontario Medical Association (OMA). The Emperor refuses to heed the advice of the Senate.

The OMA has responded with an official policy of public advocacy and awareness. It is well intentioned, but perfectly obvious to all involved that this tact will fail to produce political dividends. Despite its low likelihood of leading to policy changes, some physicians may be appeased by the OMA’s actions. Unfortunately, one can hardly blame the OMA. What else is there for an organization lacking the means to exert any form of meaningful recourse? What else is there but bread and circuses?

This is not a policy brief advocating for any particular kind of action. This is instead a prophecy for Canadian health care. Rome will fall. This article is interested in how it will fall and what will rise from the ashes.

Our public access health care system is one of the biggest misconceptions surrounding the Canadian identity. Canadians pride themselves on the grandeur of our system and mock the Americans for the inefficiencies in theirs. We support the idea of our health care system with a religious devotion, making it immune to critique and impervious to logic. It is almost humorous, that for all our zealotry, the Canadian health care system is one of the worst of any developed nation. Many other countries have much more extensive public systems, offering coverage for optometry, dentistry, home care and pharmaceuticals while costing much less. Dramatic structural changes to the Canadian health care system are not only inevitable, but will likely prove advantageous in the long run.

As doctors gain more public support and the economic benefits of further pay cuts become marginal and untenable, the government will abandon this plan of attack. Instead, the government will scour for cost savings within the health care system. It will find some, particularly within hospitals stifled by expensive bureaucracy, but not enough to offset ever growing health care costs. Next, we will see funded services be cut with increasing frequency in a fruitless effort to stave off costs. It will begin with simple blood tests that few notice missing before progressing to increasingly important treatment options. This is already happening in the United Kingdom, whose health care system shares a similar plight (though perhaps for different reasons). In January 2015, the NHS defunded 25 cancer treatments, cutting short the lives of approximately eight thousand patients. When philosophical grumblings about health care became hard realities faced by baby boomers entering the latter part of their life, health care will become a national issue. The defunding of important services, a decline in the quality of care and even longer wait times are not acceptable when you are in your 70s, 80s, 90s or beyond.

When health care becomes the election issue, each party will present their own vision for what health care ought to be and none will resemble our current system. Variations on similar ideas will emerge throughout the provinces. Hospitals will receive considerable pay cuts as non-hospital medical centers like long-term care facilities receive increased funding. Health care will finally become more distributed with hospitals losing their stranglehold over the heart of medicine. Regulations surrounding billing will gradually loosen as the government embraces elements of the free market. Physicians will begin to splinter off from the public system, resulting in more private practices and clinics. Health care will continue to grow at a rate that exceeds inflation, but this growth will be largely financed by entrepreneurs and willing members of the public without depleting government coffers.

Health care will slowly become sustainable, unfortunately first it will burn.